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Radiographic tumor regression as a predictor for pathologic response after neoadjuvant therapy for non-small cell
Justin M Bader1, Theresa Ermer1, William de Santis1
1Division of Thoracic Surgery, Department of Surgery, Yale New Haven Hospital, New Haven, Conn.
Objective:
This study evaluated correlations between radiographic tumor response and pathologic response to neoadjuvant therapy in non-small cell lung cancer.
Methods:
All patients with stage IB-IV non-small cell lung cancer treated with neoadjuvant therapy and surgery between 2015 and 2025 in a large health system were included. Demographics, pathologic, treatment, and radiographic data were collected. Per Response Evaluation Criteria In Solid Tumors 1.1, patients were stratified by radiographic tumor size decrease ≥30% from baseline (objective radiographic response, ORR) versus decrease <30% (radiographic stable disease). Major pathologic response and pathologic complete response (pCR) were determined by pathologist review.
Results:
Among 79 patients with computed tomography scans taken before neoadjuvant therapy and before surgery, 63 patients had pathologic tissue evaluation, with 44% (n = 35) showing ORR. Patients with ORR were more likely to attain pCR (33% vs 10%, P = .048) and had lower mean percentage residual viable tumor (19% vs 33%, P = .030). Radiographic size and positron emission tomography maximum standardized uptake value decrease demonstrated linear associations with lower percentage of residual viable tumor after neoadjuvant therapy (R2 = 0.14, P = .0049 and R2 = 0.28, P = .0025, respectively). Among patients with ORR, 43% (10/23) did not have major pathologic response, reflecting persistent viable tumor in many patients with ORR. Programmed cell death ligand 1 status, tumor histology, and specific neoadjuvant treatments were not associated with radiographic or pathologic response.
Conclusions:
Radiographic reduction in tumor size and decreased PET SUVmax were significantly associated with pCR after neoadjuvant therapy. Although most patients with ORR attained pCR, viable tumor persisted in some patients with ORR and, conversely, there were some patients who had complete or major pathologic response despite radiographic stability after neoadjuvant therapy. Our findings demonstrate that radiographic response can reflect pathologic response, and with further validation, may provide an objective marker for long-term outcomes.
